Pharmacotherapeutic decision-making for patients with atrial fibrillation

To discuss the therapeutic goals in patients with atrial fibrillation (AF); antithrombotic, rate-control, and rhythm-control medications used in these patients; rationale for choosing between rate-control and rhythm-control strategies; and safety, efficacy, and patient-specific considerations in choosing among established antiarrhythmic medications for these patients.

The three primary goals for patients with AF are prevention of thromboembolic stroke, heart rate control, and rhythm control. Warfarin is more effective than aspirin for stroke prevention in patients with AF, and it is recommended for patients at high risk for stroke. However, warfarin is underused, especially in elderly patients. Diltiazem, verapamil, beta-blockers, digoxin, and amiodarone may be used for rate control; the choice among these agents is based on the patient's blood pressure and the presence of certain underlying diseases. Rhythm-control strategies for patients with AF offer no advantage over rate-control strategies in terms of mortality or quality of life, and they are associated with a higher rate of hospitalization. Exercise tolerance is greater with rhythm control, however. The choice among antiarrhythmic agents for maintenance of sinus rhythm after cardioversion is based on safety, efficacy, and the presence of underlying structural heart disease (e.g., heart failure, coronary artery disease, hypertension with or without left ventricular hypertrophy) and renal impairment.

Careful consideration of patient-specific characteristics and the differences in safety and efficacy among antithrombotic, rate-control, and rhythm-control medications is needed to optimize treatment of and outcomes in patients with AF.